“What do you say to them?” investigating and supporting the needs of lesbian,gay, bisexual,trans, and questioning (LGBTQ) young people

This study explores the experiences and support needs of lesbian, gay, bisexual, transgender and questioning (LGBTQ) young people living in Sussex (UK), and the training needs of practitioners working with LGBTQ young people. The aims were to explore the experiences of young people including bullying, “coming out,” social service and educational needs, and to investigate how practitioners view the needs of LGBTQ young people. Twenty‐nine interviews were conducted and analyzed thematically. Participants stressed the social and health impact of discrimination and bullying on young people as well as barriers faced in accessing services. Young people require support, yet practitioners lack the training to provide that support. Practitioners are open to this training and both groups of participants believe effective training should include youth in the development and delivery. There is an urgent need for the development of appropriate and dedicated LGBTQ youth training for all practitioners working with young people. © 2011 Wiley Periodicals, Inc.     

Providing services in remote and rural Australian communities

A needs analysis was conducted of people with disabilities living in remote and rural areas of New South Wales (NSW), Australia. The nature of service provision generated the widest range of comments during data collections which were conducted through consultations, interviews, and field trips. This paper integrates issues raised in the literature about the nature of work in rural and remote areas with information gathered from service providers and consumers working in country areas of NSW. Clients or consumers (people with disabilities, their families, and care-providers) reported many negative encounters with services. Many service providers said that they were working under difficult conditions and felt that they did not obtain adequate support or recognition from their organizations. Many city-based agencies had given little attention to the appropriateness of their services within remote and rural areas. Other agencies were aware of deficits but were unclear as to how to address them. The article closes with a discussion of action-oriented strategies designed to address issues associated with the nature of work in Australian rural and remote areas. © 1997 John Wiley & Sons, Inc.     

A pharmaceutical needs assessment in a primary care setting.

BACKGROUND: As part of a reconfiguration of its general medical services, Ardach Health Centre has integrated a community pharmacist into the centre to provide pharmaceutical care. In order to systematically identify areas of 'pharmaceutical need', a needs assessment was carried out during October 1997. AIM: To prioritize and assist the planning of pharmaceutical care provision within the centre, such that maximum gain could be achieved from inevitable limited resources. METHOD: A four-stage pharmaceutical needs assessment method was created around a selection of techniques: gap analysis, the nominal group technique, and rapid participatory appraisal. This was then applied to a random sample of people drawn from the patient register of Ardach Health Centre and all the health care professionals associated with their care. RESULTS: Through the four-stage process, a pharmaceutical service priority league table was constructed to reflect the unmet pharmaceutical needs of patients and their primary health care providers. The table provided a structured framework around which pharmaceutical service provision within the health centre could be planned. CONCLUSION: We have developed a pragmatic, systematic method of identifying the prevalence of unmet pharmaceutical needs of a community. The assessment assisted service selection, balancing what should be done with what could be done and what could be afforded.     

Parenting a child with chronic illness as they transition into adulthood: A systematic review and thematic synthesis of parents’ experiences

ObjectiveTo understand how parents view and experience their role as their child with a long-term physical health condition transitions to adulthood and adult healthcare services.MethodsFive databases were systematically searched for qualitative articles examining parents’ views and experiences of their child’s healthcare transition. Papers were quality assessed and thematically synthesised.Results: Thirty-two papers from six countries, spanning a 17-year period were included. Long-term conditions were diverse. Findings indicated that parents view their child’s progression toward self-care as an incremental process which they seek to facilitate through up-skilling them in self-management practices. Parental perceptions of their child’s readiness, wellness, competence and long-term condition impacted on the child’ progression to healthcare autonomy. A lack of transitional healthcare and differences between paediatric and adult services served as barriers to effective transition. Parents were required to adjust their role, responsibilities and behaviour to support their child’s growing independence.ConclusionParents can be key facilitators of their child’s healthcare transition, supporting them to become experts in their own condition and care. To do so, they require clarification on their role and support from service providers.Practice implicationsInterventions are needed which address the transitional care needs of parents as well as young people.     

Prevalence and correlates of perceived unmet needs of people with systemic lupus erythematosus

To assess the prevalence and correlates of perceived unmet need among people with systemic lupus erythematosus (SLE) 386 people with SLE, recruited from a support association in NSW, Australia, completed a mail-back survey that included 97 items measuring perceived unmet needs across seven domains: physical, daily living, psychological/spiritual/existential, health services, health information, social support and employment/financial. Ninety-four percent of participants had at least one unmet need. The highest levels of unmet need were tiredness (81%); pain (73%); not being able to do things one used to (72%); fear of exacerbation (72%); sleeping problems (70%); anxiety and stress (69%); and feeling down (68%). Five of the highest levels of unmet needs were in the psychological domain. Researchers concluded that current health care delivery is not adequately meeting some of the needs of people with SLE. A comprehensive needs assessment questionnaire for all SLE patients could help providers manage protocols more effectively.     

Factors supporting good partnership working between generalist and specialist palliative care services: a systematic review

Background

The care that most people receive at the end of their lives is provided not by specialist palliative care professionals but by generalists such as GPs, district nurses and others who have not undertaken specialist training in palliative care. A key focus of recent UK policy is improving partnership working across the spectrum of palliative care provision. However there is little evidence to suggest factors which support collaborative working between specialist and generalist palliative care providers

Aim

To explore factors that support partnership working between specialist and generalist palliative care providers.

Design

Systematic review.

Method

A systematic review of studies relating to partnership working between specialist and generalist palliative care providers was undertaken. Six electronic databases were searched for papers published up until January 2011.

Results

Of the 159 articles initially identified, 22 papers met the criteria for inclusion. Factors supporting good partnership working included: good communication between providers; clear definition of roles and responsibilities; opportunities for shared learning and education; appropriate and timely access to specialist palliative care services; and coordinated care.

Conclusion

Multiple examples exist of good partnership working between specialist and generalist providers; however, there is little consistency regarding how models of collaborative working are developed, and which models are most effective. Little is known about the direct impact of collaborative working on patient outcomes. Further research is required to gain the direct perspectives of health professionals and patients regarding collaborative working in palliative care, and to develop appropriate and cost-effective models for partnership working.     

Early intervention services in youth mental health

Mental and substance use disorders are leading contributors to the burden of disease among young people in Australia, but young people experience a range of barriers to accessing appropriate treatment for their mental health concerns. The development of early intervention services that provide accessible and effective mental health care has the potential to reduce the individual and community burden associated with mental health problems. Collaborative care arrangements between general practitioners, psychologists and other service providers are a key component of comprehensive and integrated early intervention services, with evidence-based psychological treatments an important part of these collaborative mental health care models. Recently, the Australian Government funded headspace (the National Youth Mental Health Foundation) to promote and support early intervention in youth mental health by establishing accessible and collaborative models of enhanced primary mental health care for young people with emergent mental and substance use disorders. Clinical psychologists in the headspace Community of Youth Service and other settings will play a key role in providing early and effective interventions within multidisciplinary collaborative care arrangements.     

Diagnostic ultrasound: a primary care-led service?

BACKGROUND: A training programme has been proposed for general practitioners (GPs) to perform ultrasound in primary care. This has generated considerable concern among radiologists as to the adequacy and appropriateness of such training. AIM: To assess the current provision of ultrasound services to primary care in the former Northern health region of England, the level of interest among GPs in undertaking recommended training, and the willingness or ability of radiology departments to provide it. METHOD: Postal questionnaires were sent to GPs (n = 334), their practice managers (n = 281) and all clinical directors/heads of radiology departments (n = 19) in the region. RESULTS: Altogether, 67% of GPs, 59% of practice managers, and 68% of radiologists returned questionnaires. Overall, 48% of GPs have open access to obstetric/gynaecological ultrasound compared with 77% for general diagnostic requests. A total of 73% of GPs would prefer an open access service and 15% a practice-based service. Some 48% of GPs were not interested, 36% moderately interested, and 16% very interested in participating in the training programme. Only two out of 13 radiology, departments were willing to provide such training. CONCLUSION: Despite recommendations from the Royal College of General Practitioners, around half the respondents in this survey do not have direct access to ultrasound for obstetric referrals, and a quarter for non-obstetric referrals. Interest shown by GPs in a primary care-led service is not mirrored by their radiology colleagues. Open access to ultrasound was considered the optimum service, suggesting that resources be targeted at improving hospital services rather than transferring facilities to primary care.     

A new GP with special interest headache service: observational study

BACKGROUND: There is poor access to neurology services for patients in the community. AIM: To describe the training of GPs with special interest (GPwSI) in headache and the setting up of a GPwSI clinic in general practice, and report on a comparison with the existing neurology service in terms of case severity, patient satisfaction, and cost. DESIGN OF STUDY: New service provision and evaluation by a questionnaire survey. SETTING: General practice and hospital neurology service in inner-city London. METHOD: The intervention involved training GPs as GPwSIs and setting up a GP headache service. A questionnaire survey was conducted, measuring headache impact, satisfaction, and cost estimates. RESULTS: Headache impact was not significantly different between the two groups of patients, referred to hospital and to a GPwSI. Patients were significantly more satisfied with the GPwSI service, particularly that the service was effective in helping to relieve their symptoms (89% versus 76%; adjusted odds ratio=7.7; 95% confidence interval=2.7 to 22.4). The cost per first appointment was estimated to be pound sterling 136, with pound sterling 68 for subsequent contacts. These are lower than costs for neurologist contacts. CONCLUSION: GPwSI services can satisfy the needs of patients with similar headache impact at costs that are lower than those for secondary care services.     

Adult cystic fibrosis patients' experiences of primary care consultations: a qualitative study

BACKGROUND: "Expert patient" programmes have been introduced in the UK as a new approach to chronic disease management for the 21st century. The average survival age of those with cystic fibrosis (CF) has steadily increased such that the majority of those with the condition now live into adulthood. Currently, specialist CF centres deliver the core of medical care, with primary care providing access to prescribed medicines, referral to other services, and care of non-CF needs, however, it is necessary to provide a more comprehensive service for adult CF patients, involving both specialist centres and primary care. To date, little is known about these expert patients' experiences of primary care. AIM: To investigate how young adults with CF perceive and experience primary healthcare services. DESIGN OF STUDY: Qualitative study. SETTING: One specialist CF centre in southeast England. METHOD: Interview study of 31 patients with CF, aged 18 years or over. RESULTS: Adults with CF consult in primary care on two distinct levels: as lay and expert patients. When consulting as experts, patients tend to operate as consumers of health care and perceive a satisfactory doctor-patient relationship to be influenced by three factors: GPs' understanding of how people live with CF, GPs' ability to prescribe certain specialist medications, and sensitive management of the cost of health care for adults with CF. A doctor-patient relationship based on trust and understanding is seen as desirable, but requires that these factors are addressed both by the GP and the patient. CONCLUSION: Expert patient policy has focused on the role of patients with common chronic conditions in secondary and tertiary care, with little consideration of how adults with rare chronic illness and their GPs manage health problems that can be addressed in primary care. Enabling easy access to holistic care, as well as establishing successful trusting relationships with people with long-term rare conditions, is a necessary foundation for expert patients to take an active role in their care.     

Satisfaction with pregnancy loss aftercare: are women getting what they want?

While there is increasing recognition that early miscarriage represents a significant loss experience that often provokes depression and anxiety, women’s dissatisfaction with some aspects of care received from healthcare professionals following a pregnancy loss and the potentially negative consequences of this are often less recognized. This review examines available literature to identify what comprises “treatment as usual,” how satisfied women are with the typical services they receive from healthcare personnel, and whether these services are consistent with women’s self-identified needs. Results are reviewed according to four major themes—patient satisfaction with: attitudes of healthcare providers, provision of information, interventions provided, and follow-up care. In general, women and families who have experienced a miscarriage report low levels of satisfaction in the presence of perceived negative attitudes from healthcare providers, insufficient provision of information, and inadequate follow-up care that did not focus on emotional well-being. Higher levels of satisfaction are reported among women whose providers were emotionally attuned to the magnitude of the loss, provided information, and involved women in treatment decisions when possible. Limitations of current research are reviewed and directions for future research, training, and practice are briefly discussed.     

Management of deliberate self harm in general practice: a qualitative study.

BACKGROUND: It has been estimated that the incidence of deliberate self harm (DSH) is at least 10 times that of suicide. Accident and emergency discharge figures also point to an almost doubling of reported cases of DSH in the early 1990s. AIM: To assess general practitioners' (GPs') views on, and educational requirements for, managing patients following an episode of DSH. METHOD: A qualitative study with 14 GPs (seven male and seven female) from two outer-London boroughs, selected in order to provide a maximum variety sample. Interviews took place between February and April 1997, and data were analyzed using the principles of grounded theory. RESULTS: Most GPs felt that all patients presenting with DSH should be assessed by a psychiatrist. They expressed a preference for working with a community psychiatric nurse rather than a counsellor. Suggestions to improve their working relationship with community mental health teams included provision of one centralized point of referral and ease of access to the service in times of crisis. GPs were sceptical of guidelines, emphasizing that they needed joint ownership in writing them, but most importantly that they needed adequate resources to implement them. Specific changes to postgraduate education were suggested, such as individual educational portfolios. CONCLUSION: Improved working relationships between GPs and community mental health teams are needed in order to provide a more efficient and effective service for patients. Lifelong learning needs to be adapted in a style and approach to suit GPs' individual requirements.     

Perceived interprofessional barriers between community pharmacists and general practitioners: a qualitative assessment.

BACKGROUND: There have been calls for greater collaboration between general practitioners (GPs) and community pharmacists in primary care. AIM: To explore barriers between the two professions in relation to closer interprofessional working and the extension of prescribing rights to pharmacists. DESIGN OF STUDY: Qualitative study. SETTING: Three locality areas of a health and social services board in Northern Ireland. METHOD: GPs and community pharmacists participated in uniprofessional focus groups; data were analysed using interpretative phenomenology. RESULTS: Twenty-two GPs (distributed over five focus groups) and 31 pharmacists (distributed over six focus groups) participated in the study. The 'shopkeeper' image of community pharmacy emerged as the superordinate theme, with subthemes of access, hierarchy and awareness. The shopkeeper image and conflict between business and health care permeated the GPs' discussions and accounted for their concerns regarding the extension of prescribing rights to community pharmacists and involvement inextended services. Community pharmacists felt such views influenced their position in the hierarchy of healthcare professionals. Although GPs had little problem in accessing pharmacists, they considered that patients experienced difficulties owing to the limited opening hours of pharmacies. Conversely, pharmacists reported great difficulty in accessing GPs, largely owing to the gatekeeper role of receptionists. GPs reported being unaware of the training and activities of community pharmacists and participating pharmacists also felt that GPs had no appreciation of their role in health care. CONCLUSION: A number of important barriers between GPs and community pharmacists have been identified, which must be overcome if interprofessional liaison between the two professions is to be fully realised.     

Prioritising referrals to a community mental health team.

BACKGROUND: Current national policies encourage prioritisation of people with severe mental illness (SMI) as well as the development of a primary care-led National Health Service. Where resources for mental health are limited, there is a potential conflict between the needs of people with SMI and the much more common depressive and anxiety disorders that form the bulk of the mental health workload in primary care. AIM: To describe the re-organisation of a community mental health team in order to prioritise people with SMI. METHOD: The number and type of referrals received in the 12 months before and after re-organisation were compared, and general practitioners' (GP) views on the changes sought. RESULTS: There was a significant reduction in GP referrals of patients with less severe disorders in the second year. In both years the proportion of patients with a possible psychotic diagnosis or risk of self-harm was much higher among referrals from within the psychiatry department (92% of referrals) than among GP referrals (20% of referrals). Using data from a postal survey, 46% of referring GPs reported a significant improvement in the service provided to patients with SMI, but 34% reported a deterioration in services for other patient groups. GPs were more likely to be satisfied with the service for people with SMI than with the service for other patient groups. CONCLUSIONS: Improvements in the service provided for those with SMI can be achieved, but this may be at the expense of services for other patient groups. Primary care groups will need to consider this potential conflict in setting priorities for mental health.     

Service providers’ experiences of using a telehealth network 12 months after digitisation of a large Australian rural mental health service

BackgroundDespite evidence of benefits of telehealth networks in increasing access to, or providing, previously unavailable mental health services, care providers still prefer traditional approaches. For psychiatric assessment, digital technology can offer improvements over analog systems for the technical and, subsequently, the social quality of provider-client interaction. This is in turn expected to support greater provider uptake and enhanced patient benefits.ObjectiveWithin the framework of Innovation Diffusion Theory, to study service providers’ experiences of an existing regional telehealth network for mental health care practice twelve months after digitisation in order to identify the benefits of digital telehealth over an analog system for mental health care purposes in rural Australia.MethodsQualitative interviews and focus groups were conducted with over 40 service providers from June to September 2013 in South Australia, ranging from the metropolitan central operations to health providers located up to 600 km away in rural and remote areas of the same state. Participants included rural mental health teams, directors of nursing at rural hospitals, metropolitan-based psychiatrists and registrars, the metropolitan-based mental health team dedicated to rural provider support, rural GPs, administrative staff, and the executive group of the state rural health department. Fieldwork was conducted 12 months after the analog system was digitised. The interview and focus group data were analysed using thematic analysis, focusing on three key areas of innovation diffusion theory: relative advantage, technical complexity and technical compatibility.ResultsFive themes with 11 sub-themes were identified: (1) “Existing Uses”, with three sub-themes: current mental health use, use by GPs, and use for staff support; (2) “Relative Advantage”, with four sub-themes: improved technical quality, improved clinical practice, time and cost benefits for providers, and improved patient care; (3) “Technical Complexity”; (4) “Technical Compatibility” with two sub-themes: technical-clinical and technical-administrative; and (5) “Broader Organisational Culture”, with two sub-themes: organizational policy support and ‘digital telehealth' culture.ConclusionsThe digitised telehealth network was generally well received by providers and adopted into clinical practice. Compared with the previous analog system, staff found advantages in better visual and audio quality, more technical stability with less “drop-out”, less time delay to conversations and less confusion for clients. Despite these advantages, providers identified a range of challenges to starting or continuing use and they recommended improvements to increase uptake among mental health service providers and other providers (including GPs), and to clinical uses other than mental health. To further increase uptake and impact of telehealth-mediated mental health care in rural and remote areas, even with a high quality digital system, future research must design innovative care models, consider time and cost incentives for providers to use telehealth, and must focus not only on technical training but also how to best integrate technology with clinical practice and must develop an organization-wide digital telehealth culture.     

GP and nurses' perceptions of how after hours care for people receiving palliative care at home could be improved: a mixed methods study

Background  

Primary health care providers play a dominant role in the provision of palliative care (PC) in Australia but many gaps in after hours service remain. In some rural areas only 19% of people receiving palliative care achieve their goal of dying at home. This study, which builds on an earlier qualitative phase of the project, investigates the gaps in care from the perspective of general practitioners (GPs) and PC nurses.     

A review of family planning services by general practitioners in a health board region

In 1994 the North Eastern Health Board published a study, which ascertained the range of family planning services provided by General Practitioners (GPs) in the area. This study highlighted some service and training needs, which have since been addressed. This study has been repeated to evaluate service developments. All GPs on the NEHB mailing list were sent a pre-piloted questionnaire about the range of family planning services they provide, their referral patterns should they not provide the service themselves and their comments on how the health board could assist in the enhancement of family planning services. The data were analysed using the software package JMP and statistical analysis was carried out using either the Chi-square test or Fishers exact test. There was a response rate of sixty six percent. There has been a decrease in the number of GPs in single-handed practices (24% vs 50% in 1994) and an increase in the number of practices who employ a practice nurse. Almost one third of GPs providing family planning services are women (18% in 1994) and over half of GPs hold a family planning certificate (33% in 1994). The range of services provided has increased and more GPs are now fitting intrauterine contraceptive devices (19% vs 14%). This study highlights significant developments in the family planning service and indicates that general practice is capable of providing a fully comprehensive service.     

Comorbidity: Coexisting substance use and mental disorders in young people

Young people with comorbid disorders (coexisting mental health and substance use disorders) present with particular issues that can be difficult for service providers, and for the community as a whole, to respond to. They tend to fall between the cracks of mental health services and substance use services, with the outcome often being ineffective treatment, or no treatment at all, for the young people concerned, and increasing conflict, ideological clashes and blame between agencies. There is urgent need for better communication and development of protocols between mental health services and substance use services for young people; both need to recognise and respect their differing expertise, develop coordinated treatment plans and convey this information to the wider helping services sector. Cross-training is necessary for professionals in the mental health and substance use fields.     

Addressing the problems associated with general practitioners'' workload in nursing and residential homes: findings from a qualitative study.

BACKGROUND: Caring for older people in residential and nursing homes makes major demands on general practitioners (GPs). AIM: To investigate the perceptions and experiences of home managers and GPs of the provision of general medical services for older residents. DESIGN OF STUDY: In-depth qualitative study. SETTING: Forty-two nursing and residential homes in five locations in England, interviewing home managers and eight of their residents' GPs. METHOD: Semi-structured face-to-face and telephone interviews. RESULTS: Most homes endorse principles of continuity of care and patient choice. Although many homes therefore deal with a large number of GPs, with the inherent difficulties of coordinating care and duplication of GP effort, limitations in residents' choice of GP result in the majority of residents in many homes being registered with only one or two practices. Contracts between homes and GPs may provide opportunities for improving medical care but do not guarantee additional services and have implications for patient choice and residents' fees. Visits on request form the bulk of GPs' workload in homes but can be hard to obtain for residents and may not be appropriate. Regular weekly surgeries are preferred by many homes but may have additional workload implications for GPs. CONCLUSION: The assumption that patient choice and continuity in medical care are paramount for older people in nursing and residential homes is questioned. While recognition of the additional workload for GPs working in these settings is necessary, this should be accompanied by additional NHS remuneration. Further research is urgently required to identify which models of GP provision would most benefit both residents and GPs.